Yadis, a 40-year-old homeless drug user in San Juan who asks that her last name be withheld, says the community-based group Iniciativa Communitaria has been “a blessing” for her. She started using drugs when she was 14 and has suffered a variety of mental illnesses including depression. Iniciativa Communitaria offered her a warm bed, shower, detox for her cocaine habit and a supportive environment. “I have a lot of good motivation to [quit],” she says. “The drugs are worse now. They have more chemicals, more poison, and people are getting sicker. Every time it’s harder to get the money, and you want more. They make it that way.”

Injection-drug use is the leading cause of HIV infection in Puerto Rico. Recent studies have found that more than 20 percent of injection-drug users (IDUs) there are living with the virus, and approximately half of the new infections stem from injection-drug use. And for women like Yadis who aren’t injection-drug users, the combination of homelessness and addiction puts them at high risk for engaging in activities that make them vulnerable to HIV.

Created by renowned doctor Jose Vargas Vidot, Iniciativa Communitaria works to tackle the problem of drug use and other factors that play a role in HIV risk. The organization, founded in 1990, assists homeless individuals, sex workers, drug users, high school dropouts and other people at high risk for contracting HIV. In recent years, Dr. Vargas Vidot has been forced to shift his personnel after budget cuts, switching full-time workers to part-time and relying heavily on the hard work of volunteers. A program directed at sex workers took the hardest hit—in 2007, the Puerto Rican Health Department slashed funding, decreasing the number of women it served from about 1,775 to around 600.

Vargas Vidot says the stigma around sex work and injection-drug use fuels the city’s reluctance to fund CBOs like Iniciativa Communitaria. “Many doctors think drug users are low-compliance people [and don’t want to waste] medications on them if they will not use them,” he says. “But that’s not [our] experience.” He adds that it has been hard to reach drug users with needle-exchange and other services because users are often moved from abandoned buildings, where they gather in the city, to remote mountainous areas. José Colón agrees: “People in Puerto Rico are begging for money because they’re IDUs, and they’re treated like criminals when they’re sick and they need medications. They’re dropping homeless people off out of the municipality, far away. How do you get back home? How do you get back to your support group?”

I spent one day as a tourist, walking around the streets of Old San Juan, visiting San Jose Church, one of the oldest churches in the Western Hemisphere, and La Fortaleza, the governor’s mansion. I passed a family of four, arms full of shopping bags, and I heard the mother ask her daughter for the time. “It’s 7 o’clock,” the girl responded. “But that’s U.S. time.”

The comment reflects the cultural and national dislocation that many Puerto Ricans experience, feeling not quite American, yet not quite foreign, either. Some activists feel that a desire to uphold Puerto Rico’s image as an exotic getaway from the States—lush beaches, luxury hotels—keeps local and federal officials from acknowledging that the Puerto Rican AIDS crisis is also a U.S. AIDS crisis. Many activists, moreover, feel that the separatist nature of the territory affects not only HIV/AIDS, but also numerous factors that lead to infection. “One of our major problems in Puerto Rico is that we are not a territory, we’re a colony,” says Lopez-Fontanez. “So if things go bad in the U.S., the impact in Puerto Rico will be tripled. We have to import almost everything [here]. The school system is also in shambles. [And] when you talk about the way the U.S. economy is right now...it’s bad over there, but triple that [for] us here.”

The most widely proposed solution for tackling the problem of delayed reimbursements and unused federal AIDS funding in Puerto Rico is a third party that would take the funds from HRSA and deliver them directly to the CBOs. Such a plan would mean acknowledging a problem within the San Juan Department of Health and Puerto Rico Department of Health, an idea neither office is quick to embrace.

The Puerto Rico Department of Health maintains that it has strived to improve care in recent years for people living with HIV/AIDS. “The government has aggressively improved responsiveness to patients, pharmaceutical providers and organizations that support treatment and prevention efforts in Puerto Rico,” Jorge Delgado-Rivas, of the department’s HIV/AIDS program, told POZ. Delgado-Rivas adds that a majority of the department’s “community partners” are reimbursed for services within 30 days and that new department initiatives—such as a pharmacy benefits manager, who will monitor and ensure treatment for ADAP-eligible patients—show the health department’s devotion to battling the island’s epidemic. “The government’s commitment to proactively addressing HIV/AIDS in Puerto Rico has never been stronger,” he says, citing added staffing to the department’s HIV/AIDS team.

Delgado-Rivas does agree that the island’s territorial status affects its HIV/AIDS treatment. “Puerto Rico would qualify for substantial federal investment if Medicaid funding rules were applied in equitable fashion to Puerto Rico,” he says. (It has a tighter Medicaid funding cap than that of the States.) “While Puerto Rico’s HIV/AIDS prevalence and infection rates are low compared to its Caribbean neighbors, they are still too high in comparison to the States.”

Third-party plans have been launched in places like the U.S. Virgin Islands and New York. The head of HIV/AIDS at HRSA, Doug Morgan, says the U.S. government will start a third-party plan only if Puerto Rico’s local governments accept it. “Essentially they would have to agree: The grantee would enter into a contract,” he says, adding that HRSA is “trying to do the best we can to work [with them], and we hope some of them have begun to make some changes.”

Through all the discouragement, there has been one source of hope—the indomitable spirit of those fighting for Puerto Ricans living with HIV. This summer, members of New York City–based advocacy group Housing Works visited the island to support an activist in the eastern city of Fajardo. Gloria Gonzalez, a former drug user, is working there to start a community-based clinic for people at high risk for HIV, including homeless injection-drug users. But Housing Works president and CEO Charles King says his organization’s role is not one of stepping in and “saving the day.” Adds King, “I think [it is] dangerous for people to think they’re going to go in and help like they know it all; [that would] do a terrible disservice to the people that are working very hard there and the people living with HIV/AIDS. [But] I think we have an absolute obligation to be working and demanding that the federal government take appropriate action.”

Still, as we come to the conclusion of yet another article about the crisis, one in which activists have again spoken out and government officials have again pledged to work to end the problem, the questions remain: Who does need to step in and save the day? Who, ultimately, is responsible for saving lives in Puerto Rico? And, when will they start?

(Note: The POZ team reviews all comments before they are posted. Please do not include either ":" or "@" in your comment. The opinions expressed by people providing comments are theirs alone. They do not necessarily reflect the opinions of Smart + Strong, which is not responsible for the accuracy of any of the information supplied by people providing comments.)

Gabe Gaslin, crystal, mn, usa, 2010-01-26 14:35:34
my pstner and I are from MN USA and wonder if there were benefits other than weather, for hiv poz, could we keep our benefits from USA while
living in Puerot Rico

Alfredo, Baltimore, 2008-09-30 17:13:26
I remember seeing Puerto Rican POZ advocates at USCA 2007 in CA. They were not a happy group, but how could they be? They were all aware of how the political corruption in P.R. has negatively impacted men & women living with HIV/AIDS.
In order for PLWHAs to receive health and support services, Federal funding must be better regulated to assure this happens.
Saludos y abrazos to my brothers and sister in P.R.
Que Dios los bendigan.

JR, NY, 2008-09-11 19:10:53
The theft of funds slated to treat AIDS in P.R. has been a travesty. I take my hat off to all the advocates in the island for their laborious commitment to inform the public there, as well as in the mainland. I am a 20 year survivor in the mainland, and even here HIV/AIDS is looked upon like leprosy. Please, continue to educate our Puerto Rican people, and help our brothers and sisters overcome their obstacles. Un fuerte abrazo, mis hermanos.

Hugo, Los Angeles, 2008-09-11 14:07:04
I am Puerto Rican. I left there in 1973 as a 2nd Lt. in the AF and never moved back. I have been poz since 1984. I have survived (not taking meds since fall of 2005), by following my own instinct, and not believing in superstition or relying on magical thinking. I am appalled at the ignorance, and cruelty described in the article. My parents who lived in PR tell me that the politicians in PR are all crooked. Homophobia is so prevalent. I am saddened.

Emmanuel, New York, 2008-09-08 12:38:59
Thats why i moved to New York with the purpose to find an cheaper alternative to positive people like me... Now I am a licensed acupuncturist and all what i have learned i am putting in practice with myself....Since 2001 I being fighting and I am med free and doing great...I would love to help but I am tight handed.

Jose Mariani Rosa, Minneapolis, 2008-09-02 16:33:15
As a Puerto Rican and a Medical Case Manager working with person afflected with HIV/AIDS I find this story most disturbing but know it has been true for so many years. More needs to be done to reach out and mobilize our communities our people our land. I hope that more will take an active rule in for Latino AIDS awareness during October. Rather then just talking about it get and pointing the finger. We can do so much more rather then depending on our government to do it for us.

Richard, San Antonio,PR, 2008-08-31 23:28:16
It is also true that the ADAP program does not work in Mayaguez, PR. Even the poverty level chart they use is to their own convenience and does not follow the same income rate levels than the ones in states like Florida, NY, or California. Here they kick you out just for having any private insurance from your job and not by analyzing your income versus the high deductable amount you have to pay for the medications which go over $225 a month. This leaves us even without extra $ for groceries!

Ricanguy, San Antonio,TX, 2008-08-22 10:30:47
As a puertorican, I am heart broken to hear the situation about HIV/Aids that the Island is having. Unfortunately, in my opinion the situation is all political, and don't think this will change unless PR new generation (The Youth) becomes more progressive and see that United States is our only hope to be treated as equals. After all, puertoricans are considered US citizens. Private funds (Thank God for them!) are not enough to resolve and/or stablelized this situation, Gob bless them.

Sky, New York, 2008-08-21 18:12:23
Puerto Rico has more than an HIV/AIDS problem and that is dirty politics. That island attracts major tourist from around the world. They should be self sufficient in taken care of their own people's needs. Out of any of the islands you would think that Puerto Rico would be a prime example of having an excellent health care system. I say boycott the Island until they clean up their act. Let everyone feel the pressure until they wise up, I bet that would stop the corruption fast.

machito65, Miami Beach, 2008-08-21 14:52:44
Its sad being Puerto Rican and living in the mainland and reading about this crisis. It makes me want to move there and take all of my knowledge I acquired working in Preventiona and Care and contribute something positive that would help those who are in need. Yet I know how the politics works there. Complaining and fighting is good and hopefully this article would wake up some people. Until that occurs, organizations that do exist in PR need to focus on fundraising. I will pray for all of you

PRMike, St cloud Fla, 2008-08-21 11:31:16
I would love to be able to go to Puerto Rico but I can not get my SSI there and I am afraid that I would not be able to get my Meds there, I hear that the goverment there really does not care wheather you live or Die if your infected with HIV/Aids so until things get better there I guess I will not be seeing my beautiful Island, It's a shame but I truly beleive that the US should do something about it, thank you sincerly PRMike

Antonio, San Juan, 2008-08-20 20:30:47
The article fails to mention the responsibility of the PR Catholic and Pentecostal churches for this crisis. We have no real sex education or condom distribution by the gov, thanks to the constant threat of Church leaders to direct their flocks to vote against any government that dares to promote those life saving strategies. At present the main strategy of the gov is a hateful TV campaign that depicts HIV positive people as predatory monsters seeking out young people to destroy their lives.

mom living da life, , 2008-08-20 12:36:13
im in PR now on vacation my family dat know want me 2 come live here pos since 2007 i told them no cause i wont get da same treatment i get in the US & reading this article confirms that. Its very sad because i would luv to stay in PR with my family i wish like so many of us that we could change the treatment of hiv pos in PR i will show this article 2 my family they really believe i'll get the same treatment here as in the US but unfortunately its not so